The nurse is gathering data on a client. Which data will the nurse report as objective data? Select all that apply
The patient feels nauseous
The patient reports a headache
The patient is pacing the floor
The patient's BP is 130/60
Scant drainage noted during dressing change
The patient states they have lost their appetite
Correct Answer : C,D,E
A. Nausea is a subjective sensation that can only be described and verified by the patient experiencing it. The nurse cannot physically observe or measure the feeling of being sick to one's stomach. While the nurse can observe the act of emesis, the underlying sensation remains a subjective "symptom" rather than an objective "sign."
B. A headache is a subjective report of pain that is entirely dependent on the patient's personal perception and communication. There is no external diagnostic tool used at the bedside that can quantify the presence or intensity of a cephalalgia. Pain is always considered subjective data in the nursing process because it is what the patient says it is.
C. Pacing the floor is an objective observation of a physical behavior that can be seen and documented by any observer. This kinetic activity is a visible manifestation of possible anxiety or restlessness. Since it does not rely on the patient's verbal report, it is classified as objective data obtained through the nurse's sense of sight.
D. Blood pressure is a definitive objective measurement obtained through a standardized clinical procedure using a sphygmomanometer. It provides a numerical value that represents the physiological state of the patient's cardiovascular system. This data is reproducible and independent of the patient's opinion or feelings, making it a cornerstone of objective clinical assessment.
E. Observing wound drainage during a dressing change is a form of objective data collection using visual inspection. The nurse can describe the color, odor, and amount (scant) of the exudate. Because this information is based on the nurse's direct observation of a physical finding, it is considered objective and verifiable evidence of wound healing.
F. A loss of appetite, or anorexia, is a subjective report provided by the patient regarding their internal desire to eat. While the nurse can objectively measure a decrease in actual caloric intake, the stated "feeling" of not being hungry is subjective. It reflects the patient's internal state and cannot be independently observed by the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.Touching the front of the mask while it is being worn is a violation of aseptic technique because the outer surface is considered contaminated. Pathogens trapped on the filter fibers can be transferred to the hands, increasing the risk of cross-contamination to other surfaces or the face. Proper protocol dictates that the mask should only be handled by the ear loops or ties during adjustment or removal.
B.Discarding the mask after each use is essential to prevent the spread of microorganisms and ensure the integrity of the filtration material. Moisture from respirations can saturate the mask over time, significantly reducing its efficacy as a barrier against respiratory droplets. Single-use medical masks are designed for one clinical encounter or until they become soiled to maintain optimal infection control standards.
C.According to standard doffing sequences, the mask should be removed after the gloves and gown have been taken off and hand hygiene has been performed. Gloves are considered heavily contaminated and should never be used to touch the head or face area. Removing the mask earlier in the sequence increases the risk of transferring pathogens from dirty gloves to the wearer's respiratory mucosa.
D.The flexible metal piece must be positioned at the top of the mask, over the bridge of the nose, to ensure a proper fit. Pressing this strip against the contours of the nose prevents gaps that would allow unfiltered air to enter or exit. Placing the metal piece at the bottom would leave the nose exposed and compromise the protective function of the personal protective equipment.
Correct Answer is A
Explanation
A.Engaging the safety mechanism immediately after withdrawing a needle from a patient is the most effective way to prevent accidental percutaneous injuries. This action shields the contaminated sharp before any transport or disposal occurs. Prompt activation reduces the window of time during which an exposed, contaminated needle poses a biological hazard to the healthcare worker.
B.All needles, regardless of gauge or bore size, must be disposed of in puncture-resistant, leak-proof sharps containers rather than standard wastebaskets. Waterproof wastebaskets do not provide the necessary physical barrier to prevent needles from piercing the sides and injuring staff. Proper disposal in designated sharps bins is a fundamental requirement of OSHA bloodborne pathogen standards.
C.Bending, breaking, or recapping needles is strictly prohibited because these actions significantly increase the risk of an accidental needlestick. Manipulating a contaminated sharp brings the nurse's hands into close proximity with the needle point, leading to high rates of injury. Needles should be disposed of intact into a sharps container immediately following their clinical use.
D.Sharps containers should be replaced when they are 75% full to prevent overfilling and the risk of needles protruding from the opening. Attempting to use a container until it is completely full often leads to "shunting" or forcing sharps inside, which is a common cause of injury. Maintaining a clear safety margin at the top of the container ensures safe disposal.
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